Basics in clinical nutrition Fifth Edition Editor in Chief Luboš Sobotka Associate Editors Simon P. Allison Alastair Forbes Rémy F. Meier Stéphane M. Schneider Peter B. Soeters Zeno Stanga Andre Van Gossum Galén Basics in clinical nutrition Fifth Edition Editor in Chief Luboš Sobotka Associate Editors Simon P. Allison Alastair Forbes Rémy F. Meier Stéphane M. Schneider Peter B. Soeters Zeno Stanga Andre Van Gossum Galén Basics in Clinical Nutrition 5.indd 3 5.8.2019 11:45:00 BASICS IN CLINICAL NUTRITION Fifth edition Editor in Chief Luboš Sobotka Publishing House Galén Na Popelce 3144/10a, 150 00 Prague 5, Czech Republic Managing Editor Lubomír Houdek, Dr. Editor-in-Chief Soňa Dernerová, Dr. Composition Václav Zukal – Galén, Prague Print FINIDR, s. r. o., Lipová 1965, 737 01 Český Těšín, Czech Republic www.espenbluebook.org All rights reserved. This book, or any thereof, may not be used or reproduced in any manner without written permision. For information, address European Society of Parenteral and Enteral Nutrition. Supported by the program PROGRES Q40/12. © ESPEN, 1999, 2000, 2004, 2011, 2019 © Galén, 1999, 2000, 2004, 2011, 2019 ISBN 978-80-7492-427-9 Basics in Clinical Nutrition 5.indd 4 5.8.2019 11:45:00 V Editor in Chief Luboš Sobotka, MD, PhD Professor of Medicine 3rd Department of Medicine Metabolic Care and Gerontology Medical Faculty – Charles University Hradec Králové Czech Republic Associate Editors Simon P. Allison, MD, FRCP Professor in Clinical Nutrition Department of Diabetes, Endocrinology and Nutrition Queen’s Medical Center Nottingham United Kingdom Alastair Forbes, BSc, MD, FRCP, FHEA Clinical Professor of Medicine Chief of Research and Innovation Norwich Medical School University of East Anglia Norwich United Kingdom Rémy F. Meier, MD Professor of Medicine Head of Department of Gastroenterology, Hepatology and Nutrition University Hospital Kantonsspital Liestal Liestal Switzerland Stéphane M. Schneider, MD, PhD, FEBGH Professor of Nutrition Nutritional Support Unit Archet University Hospital Nice France Basics in Clinical Nutrition 5.indd 5 Peter B. Soeters, MD, PhD Emeritus Professor of Surgery Department of Surgery University Hospital Maastricht Maastricht The Netherlands Zeno Stanga, MD, PhD Professor in Internal Medicine and Clinical Nutrition Division of Endocrinology, Diabetes and Clinical Nutrition Division of General Internal Medicine University Hospital Bern Switzerland Andre Van Gossum, MD, PhD Professsor Head of the Clinic of Intestinal Diseases and Nutritional Support Department of Gastroenterology Hopital Erasme Universite Libre de Bruxelles Brussels Belgium 5.8.2019 11:45:00 VI List of authors Michael Adolph, MD, PhD Associate Professor Head of Nutrition Support Team Senior Physician Anesthesiology and Intensive Care Medicine University Clinic Tuebingen Tuebingen Germany Carla Aeberhard, PhD Department of Endocrinology, Diabetes and Clinical Nutrition Bern University Hospital and University of Bern Bern Switzerland Simon P. Allison, MD, FRCP Professor in Clinical Nutrition Department of Diabetes, Endocrinology and Nutrition Queen’s Medical Center Nottingham, UK Raffaella Antonione, MD Internal Medicine Clinica Medica, Ospedale di Cattinara Azienda Ospedaliero-Universitaria Trieste Italy Peter Austin Senior Pharmacist Southampton University NHS Hospitals Trust Southampton United Kingdom Mette M Berger, MD, PhD Professor of Intensive care medicine Service of Intensive Care Medicine & Burns Lausanne University Hospital (CHUV) CH- 1011 Lausanne Switzerland Basics in Clinical Nutrition 5.indd 6 Basics in Clinical Nutrition Stephan C Bischoff, MD, PhD Professor of Medicine Institute of Nutritional Medicine University of Hohenheim Stuttgart Germany Gyorgy Bodoky, MD, PhD Professor of Oncology St. Laszlo Teaching Hospital Department of Oncology Budapest Hungary Prof Yves Boirie, MD, PhD University of Clermont-Ferrand Clinical Nutrition department of the University Hospital of Clement-Ferrand Human Nutrition Research Center Clermont-Ferrand France Marian A. E. van Bokhorst – de van der Schueren, RD, PhD Senior nutrition scientist Department of nutrition and dietetics VU University Medical Center Amsterdam The Netherlands Dr Kurt Boeykens Clinical Nutrition Nurse Specialist Nutrition Support Team AZ Nicolaas Hospital Sint-Niklaas Belgium Federico Bozzetti, MD Surgeon oncologist Faculty of Medicine University of Milan Milan Italy 5.8.2019 11:45:00 VII List of authors Valentina Bozzetti, MD, PhD Neonatal Intensive Unit San Gerardo Hospital Monza Italy Marco Braga, MD Professor of Surgery San Raffaele University Milan Italy Fang Cai, MD Physician Unit of Nutrition Geneva University Hospital 1211 Geneva 14 Switzerland Philip C. Calder, PhD, DPhil Professor of Nutritional Immunology Institute of Human Nutrition and Human Development and Health Academic Unit Faculty of Medicine University of Southampton Southampton General Hospital Southampton United Kingdom Maria E. Camilo, MD, PhD Professor of Medicine and Nutrition Research Unit of Nutrition and Metabolism Institute of Molecular Medicine Medical Faculty Lisbon University Lisbon Portugal Noël Cano, MD, PhD Professor of Nutrition Human Nutrition Research Center of Auvergne Human Nutrition Unit, UMR 1019 INRAClermont University Clinical Nutrition Unit, Clermont-Ferrand University Hospital Clement-Ferrand France Basics in Clinical Nutrition 5.indd 7 Anja Carlsohn, Prof, Dr Department of Ecotrophology Faculty of Life Science University of Applied Science Hamburg Germany Yvon A. Carpentier, MD Professor of Pathological Biochemistry and Nutrition L. Deloyers Laboratory for Experimental Surgery Université Libre de Bruxelles Brussels Belgium Tommy Cederholm, MD, PhD Professor of Clinical Nutrition Department of Public Health and Caring Sciences Uppsala University Uppsala Sweden Emanuele Cereda, MD, PhD Researcher and Physician Nutrition and Dietetics Service IRCCS Fondazione Policlinico San Matteo Pavia Italy Irit Chermesh, MD Deputy Director of Gastroenterology Department Medical Director of Clinical Nutrition Rambam Health Care Campus Haifa Israel Michael Chourdakis, MD, RD, MPH, PhD Assistant Professor of Medical Nutrition Dept.of Medicine Aristotle University of Thessaloniki Thessaloniki Greece 5.8.2019 11:45:01 VIII Luc Cynober, PharmD, PhD Professor of Nutrition Head of Departments Dept. of Experimental, Metabolic and Clinical Biology Pharmacy Faculty – Paris Descartes University and Clinical Chemistry Department Cochin and Hôtel-Dieu Hospitals, APHP Paris France Erno Dardai, MD, PhD Department of Anesthesiology and Intensive Therapy St. Stephen’s Hospital Budapest Hungary Sarah Delliere, MD, MS Service de Biochimie Hopital Cochin Groupe Hospitalier HUPC, APHP Paris France Nicolaas E. P. Deutz, MD, PhD Professor of Geriatrics. Professor of Pediatrics and Nutrition Center for Translational Research in Aging & Longevity Department of Health and Kinesiology Texas A&M University College Station, TX USA David F. Driscoll, PhD Vice President Stable Solutions LLC Easton, MA USA Basics in Clinical Nutrition 5.indd 8 Basics in Clinical Nutrition Wilfred Druml, MD Professor of Medicine Medical Department III Division of Nephrology University of Vienna and Vienna General Hospital Vienna Austria Stanley J. Dudrick, MD, FACS Professor of Surgery Chairman, Department of Surgery Director, Program in Surgery St. Mary’s Hospital Waterbury, CT Yale University School of Medicine New Haven, CT USA Marinos Elia, MD, FRCP Professor of Clinical Nutrition & Metabolism Institute of Human Nutrition University of Southampton Southampton General Hospital Southampton United Kingdom Nicholas D. Embleton, MD, MBBS, FRCPCH, BSc Consultant Neonatal Pediatrician Honorary Reader in Neonatal Medicine Royal Victoria Infirmary Newcastle Hospital NHS Foundation Trust Newcastle upon Tyne United Kingdom Joel Faintuch, MD, PhD Senior Professor Department of Gastroenterology Sao Paulo University Medical School Sao Paulo Brazil 5.8.2019 11:45:01 IX List of authors Joel J. Faintuch, MD, PhD Professor of Medicine Department of Medicine Hospital das Clinicas Sao Paulo University Medical School Sao Paulo Brazil Enrico Fiaccadori, MD, PhD Renal Failure Unit Division of Nephrology Parma University Hospital University of Parma Parma Italy Eric Fontaine, MD, PhD Professor of Medicine INSERM U1055 - LBFA Joseph Fourier University Grenoble Cedex France Alastair Forbes, BSc, MD, FRCP, FHEA Clinical Professor of Medicine Chief of Research and Innovation Norwich Medical School University of East Anglia Norwich United Kingdom Konstantinos C. Fragkos, MB, BS, MSc, PhD Clinical Research Fellow in Gastroenterology and Clinical Nutrition University College London London United Kingdom Wim G. van Gemert, MD, PhD Colorectal, Gastrointestinal and Pediatric Surgeon Academic Hospital Maastricht and Maastricht University Maastricht The Netherlands Basics in Clinical Nutrition 5.indd 9 Laurence Genton, MD, PhD Professor in Clinical Nutrition Clinical Nutrition Geneva University Hospital Geneva Switzerland M. Cristina Gonzalez, MD, PhD Professor of Post-Graduation Program in Health and Behaviour Catholic University of Pelotas Pelotas RS Brazil Olivier Goulet, MD, PhD Professor of Paediatrics Department of Gastroenterology Hopital Necker Enfans-Malades Paris France Robert F. Grimble, BSc, PhD, RNutr Professor of Nutrition Division of Developmental Origins of Health and Disease School of Medicine University of Southampton Southampton United Kingdom Martin Haluzík, MD, PhD Professor of Medicine Department of Experimental Diabetology Institute for Clinical and Experimental Medicine Prague Czech Republic Folke Hammarqvist, MD, PhD Professor in Emergency Surgery Department of Surgical Gastrocenter. CLINTEC – Department of Clinical Science, Intervention and Technology Karolinska University Hospital Huddinge Stockholm Sweden 5.8.2019 11:45:01 X Basics in Clinical Nutrition Gil Hardy, PhD, FRSC Professor of Pharmaceutical Nutrition Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand Philippe Jolliet, MD Senior Lecturer Medical Intensive Care Geneva University Hospital Geneva Switzerland Laszlo Harsanyi, MD, PhD Professor of Surgery 1st Surgical Department Faculty of Medicine Semmelweis University Budapest Hungary Cora F. Jonkers-Schuitema, RD, Bc Dietitian Academic Medical Center Amsterdam The Netherlands Reem Hawarym RD King Faisal Specialist Hospital & Research Center 11578 Riyadh Saudi Arabia J Pat Howard, RD Head of Nutrition and Dietetic Services United Bristol Healthcare Trust Bristol Royal Infirmary Bristol BS2 8HW United Kingdom Francisco J. Karkow, MD, PhD Full Professor Department of Nutrition Fatima Faculty Caxias do Sul Brazil Luiza Kent-Smith, PhD, RD Professional Leader Nutrition & Dietetics Saskatoon Health Region Saskatoon Canada Pao Ying Hsiao, MS, RD, LDN Assistant Professor and Registered Dietitian Department of Nutritional Sciences Pennsylvania State University USA Berthold Koletzko, MD, PhD Professor of Paediatric Division Metabolic and Nutritional Medicine Dr. von Hauner Children’s Hospital Ludwig-Maximilians-University of Munich Munich Germany Martin Hubner, MD, PD Consultant Surgeon Department of Visceral Surgery Lausanne University Hospital - CHUV Lausanne Switzerland Jens Kondrup, MD, Dr Med Sci Professor in Clinical Nutrition Clinical Nutrition Unit 5711 Rigshospitalet University Hospital, Copenhagen Denmark Gordon L Jensen, MD, PhD Professor of Medicine Head of Department of Nutritional Sciences Pennsylvania State University USA Angela Koverech, MD Department of Clinical and Molecular Medicine Sapienza University Rome Italy Basics in Clinical Nutrition 5.indd 10 5.8.2019 11:45:01 XI List of authors Zeljko Krznarič, MD, PhD, FEBGH Professor of Medicine Head of Division of Gastroenterology Department of Medicine University of Zagreb Zagreb Croatia Irma Kushta, MD Department of Clinical Medicine Sapienza – University of Rome Rome Italy Alexey V. Lapitsky, MD, PhD Research scientist Laboratory of Clinical Nutrition Saint-Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine Saint-Petersburg Russian Federation Miguel Leon-Sanz, MD, PhD Professor Endocrinology and Nutrition Department of Medicine Medical School University Hospital Doce de Octubre Complutense University Madrid Spain Olle Ljungqvist, MD, PhD Professor of Surgery Faculty of Medicine and Health, School of Health and Medical Sciences Department of Surgery Örebro University, Örebro Sweden Valery M. Luft, MD, PhD Professor, Head of Laboratory of Clinical Nutrition Saint-Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine Saint-Petersburg Russian Federation Basics in Clinical Nutrition 5.indd 11 Stanislav Klek, MD, PhD Professor of Surgery General and Oncology Surgery Unit Stanley Dudrick’s Memorial Hospital Skawina Poland Marek Kunecki, MD Specialist in General Surgery Department of Clinical Nutrition Department of General and Vascular Surgery M. Pirogow Provincial Specialist Hospital Lodz Poland Alessandro Laviano, MD Associate Professor of Medicine Department of Translational and Precision Medicine Sapienza University of Rome Rome Italy Dileep N Lobo, MS, DM, FRCS, FACS Professor of Gastrointestinal Surgery Nottingham University Hospitals Queen’s Medical Centre Nottingham NG7 2UH United Kingdom Jan Maňák, MD, PhD 3rd Department of Medicine Metabolic Care and Gerontology Medical Faculty – Charles University Hradec Králové Czech Republic Luis Matos, MSc Department of Nutrition USL Gurda Porto Portugal 5.8.2019 11:45:01 XII Michael M. Meguid, MD, PhD Professor Emeritus Surgery, Neuroscience and Physiology Department of Surgery Upstate Medical University University Hospital Syracuse, NY USA Rémy F. Meier, MD Professor of Medicine Head of Department of Gastroenterology, Hepatology and Nutrition University Hospital Kantonsspital Liestal Liestal Switzerland Katarina Melzer, PhD Equiliberty Consulting, LLC University of Lausanne Lausanne Switzerland Maarten F. von Meyenfeldt, MD, PhD Professor of Surgical Oncology Department of Surgery University Hospital Maastricht Maastricht The Netherlands Alvaro A. C. Morais, MD, MS Full Professor Department of Surgery EMESCAM Medical Scholl Vitoria Brazil Adéla Mrózková, MD Department of Hygiene and Preventive Medicine Medical Faculty Charles University Hradec Králové Czech Republic Basics in Clinical Nutrition 5.indd 12 Basics in Clinical Nutrition Stefan Mühlebach, PhD Professor of Pharmacology and Hospital Pharmacy Hospital Pharmacist FPH Medical Faculty Division of Clinical Pharmacology & Toxicology University Hospital of Basel Basel Switzerland Maurizio Muscaritoli, MD, FACN Profesor of Medicine Department of Clinical Medicine Sapienza – University of Rome Rome Italy Ton Naber, MD, PhD Professor of Clinical Nutrition Department of Gastroenterology and Hepatology Medical Faculty University Medical Center Nijmegen Nijmegen The Netherlands Luis Alberto Nin, MD Professor in Nutrition and Director Magister in Nutrition Catholic University Montevideo Uruguay Kristina Norman, PhD Professor of Nutrition and Gerontology Department of Nutrition and Gerontology German Institute for Human Nutrition Potsdam Rehbrücke University of Potsdam Potsdam Germany 5.8.2019 11:45:01 XIII List of authors Ibolya Nyulasi, MSc Department of Medicine Alfred Hospital Faculty of Medicine Nursing and Health Sciences Clayton Australia Johann Ockenga, MD, PhD Professor in Internal Medicine Department of Gastroenterology, Endocrinology and Clinical Nutrition Klinikum Bremen Mitte Bremen Germany Loris Pironi, MD Associate professor of Food and Dietetic Sciences Department of Medical and Surgical Science School of Medicine University of Bologna Bologna Italy Mathias Plauth, MD Professor of Medicine Head of Department of Internal Medicine Community Hospital Dessau Dessau Germany Ann Ödlund Olin, PhD, RN Manager of nursing development Department of Quality and Patient Safety Karolinska University Hospital Stockholm Sweden Jean-Charles Preiser, MD, PhD Clinical Director Department of Intensive Care Erasme University Hospital Brussels Belgium Olivier Pantet, MD Service of Intensive Care Medicine & Burns Lausanne University Hospital (CHUV) CH- 1011 Lausanne Switzerland John W. L. Puntis, BM (Hons), DM, FRCP, FRCPCH Consultant Paediatric Gastroenterologist The General Infirmary at Leeds Leeds, West Yorkshire United Kingdom Claude Pichard, MD, PhD Professor of Medicine Head of the Unit of Unit of Nutrition Geneva University Hospital 1211 Geneva 14 Switzerland Matthias Pirlich, MD, PhD Professor of Medicine Head of Department Department of Internal Medicine Evangelische Elisabeth Klinik Lützowstr. 24-26 10785 Berlin Germany Basics in Clinical Nutrition 5.indd 13 Petronella Lucia Martha Reijven, MSc, PhD Nutritional Scientist Department of Clinical Dietetics Maastricht University Medical Centre Maastricht, The Netherlands Filippo Rossi Fanelli MD, FACN Profesor of Medicine Department of Clinical Medicíně Sapienza – University of Rome Rome Italy 5.8.2019 11:45:01 XIV Nada Rotovnik Kozjek, MD, PhD Associate Professor of Oncology and Dietetics Institute of Oncology Clinical Nutrition Unit Medical Faculty University of Ljubljana Slovenia Hans P. Sauerwein, MD Emeritus Professor of Energy Metabolism Academic Medical Center Amsterdam The Netherlands Anastasia M. Sergeeva, MD Junior research scientist Laboratory of Clinical Nutrition Saint-Petersburg I. I. Dzhanelidze Research Institute of Emergency Medicine Saint-Petersburg Russian Federation Alan Shenkin, PhD, BSc, FRCP, FRCPath Emeritus Professor School of Clinical Sciences University of Liverpool Liverpool L69 3GA United Kingdom Stéphane M. Schneider, MD, PhD, FEBGH Professor of Nutrition Nutritional Support Unit Archet University Hospital Nice France Jos M. G. A. Schols, MD, PhD Professor of chronic care and nursing home medicine Department of General Practice Maastricht University Maastricht The Netherlands Basics in Clinical Nutrition 5.indd 14 Basics in Clinical Nutrition Philipp Shütz, MD, MPH Professor of Medicine Medical University Department Kantonsspital Aarau Aarau Switzerland Pierre Singer, MD Clinical Professor in Anaesthesia and Intensive Care Department of General Intensive Care and institute for Nutrition Research Tel Aviv University Rabin Medical Center, Beilinson Hospital Petah Tikva Israel Antonio Sitges-Serra, MD, FRCS Professor of Surgery Head of Department of Surgery University Hospital del Mar Barcelona University Barcelona Spain Jacek Sobocki, MD, PhD Professor of Surgery Department of Surgery and Clinical Nutrition Medical University of Warsaw Warsaw Poland Luboš Sobotka, MD, PhD Professor of Medicine 3rd Department of Medicine Metabolic Care and Gerontology Medical Faculty – Charles University Hradec Králové Czech Republic Ondřej Sobotka, MD, PhD 3rd Department of Medicine Metabolic Care and Gerontology Medical Faculty – Charles University Hradec Králové Czech Republic 5.8.2019 11:45:01 XV List of authors Maarten R. Soeters, MD, PhD Department of Endocrinology and Metabolism University of Amsterdam Academic Medical Center Amsterdam The Netherlands Bruno Szczygiel, MD, PhD Professor of Surgery Department of Human Nutrition Medical University of Warsaw Warsaw Poland P. B. Soeters, MD, PhD Emeritus Professor of Surgery Department of Surgery University Hospital Maastricht Maastricht The Netherlands Luc Tappy, MD Professor of Physiology Chairman, Department of Physiology School of Biology and Medicine Lausanne University Lausanne Switzerland Mattias Soop, MD, PhD Consultant surgeon Irving National Intestinal Failure Unit Salford Royal Hospital Reader Manchester University United Kingdom Zeno Stanga, MD, PhD Professor in Internal Medicine and Clinical Nutrition Division of Endocrinology, Diabetes and Clinical Nutrition Division of General Internal Medicine University Hospital Bern Switzerland Rebecca Stratton, PhD, RD, RNutr Institute of Human Nutrition University of Southampton Southampton General Hospital Southampton United Kingdom Štěpán Svačina, MD, PhD Professor of Medicine Head of the 3rd Department of Internal Medicine Medical Faculty 1 Charles University Prague Czech Republic Basics in Clinical Nutrition 5.indd 15 Vladimír Teplan, MD, PhD Profesor of Medicine Institute for Postgraduál Education Department of Nephrology Institute for Clinical and Experimental Medicíne Prague Czech Republic Ronan Thibault, MD, PhD Professor of Nutrition NuMeCan Institute CHU Rennes, Univ. Rennes, INSERM, INRA Dept. Nutrition and Endocrinology Referral Centre for Rare Digestive Diseases Home Parenteral Nutrition Centre Rennes France Christel Tran, MD Consulting Physician Division of Endocrinology Diabetes and Metabolism Lausanne University Hospital Lausanne Switzerland Elena Y. Tyavokina, MD Head of Somatopsychiatry Department Saint-Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine Saint-Petersburg Russian Federation 5.8.2019 11:45:01 XVI Nachum Vaisman, MD Professor of Pediatrics Head of Clinical Nutrition Unit Tel Aviv Sourasky Medical Center and Tel Aviv Sourasky Medical School Tel Aviv Israel Maurits F. J. Vandewoude, MD, PhD Professor of Medicine Department of Geriatrics Faculty of Medicine University of Antwerp Antwerp Belgium Andre Van Gossum, MD, PhD Professsor Head of the Clinic of Intestinal Diseases and Nutritional Support Department of Gastroenterology Hopital Erasme Universite Libre de Bruxelles Brussels Belgium Geert Wanten, MD, PhD, MSc Gastroenterologist, Head Nutrition Support Team Intestinal failure Unit Department of Gastroenterology and Hepatology Radboud University Nijmegen Medical Centre Nijmegen Nijmegen The Netherlands Basics in Clinical Nutrition 5.indd 16 Basics in Clinical Nutrition Jan Wernerman, MD, PhD Professor in Anaesthesia Department of Anaesthesia and Intensive Care CLINTEC – Department of Clinical Science, Intervention and Technology Karolinska University Hospital Huddinge Stockholm Sweden Klaas R Westerterp, PhD Professor of Human Energetics Department of Human Biology Maastricht University Maastricht The Netherlands Thomas Wild, MD Departments of Dermatology, Venereology, Allergology and Immunology Dessau Medical Center Dessau Germany Zdeněk Zadák, MD, PhD Professor of Medicine 3rd Department of Medicine, Metabolic Care and Gerontology Medical Faculty – Charles University Hradec Králové Czech Republic 5.8.2019 11:45:01 XVII Contents 1. Basic concepts in nutrition . . . . . . . . . . . . . . . . . . . . . . 1 1.1. 1.2. 1.2.1. 1.2.1.1. 1.2.1.2. 1.2.1.3. 1.2.1.4. 1.2.1.5. 1.2.1.6. 1.2.1.7. 1.2.2. 1.2.2.1. 1.2.2.2. Energy and protein balance . . . . . . . . . . 1 Body composition . . . . . . . . . . . . . . . . . . 6 Measurement of body composition . . . . 6 Background . . . . . . . . . . . . . . . . . . . . . . . . 6 Densitometry . . . . . . . . . . . . . . . . . . . . . . . 7 Hydrometry . . . . . . . . . . . . . . . . . . . . . . . . 7 Anthropometry . . . . . . . . . . . . . . . . . . . . . 8 Electrical conductance . . . . . . . . . . . . . . . 9 Body imaging . . . . . . . . . . . . . . . . . . . . . . 10 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . 10 Bioelectrical Impedance Analysis . . . . . 12 Basic principle of the method . . . . . . . . 12 Factors which influence BIA measurement . . . . . . . . . . . . . . . . . . . . . . 14 1.2.2.3. BIA as marker of tissue health . . . . . . . 15 1.2.2.4. BIA methods used in clinical practice . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1.3. Diagnosis of malnutrition – Screening and Assessment . . . . . . . . . . 18 1.3.1. Definition of Malnutrition . . . . . . . . . . . 18 1.3.1.1 Malnutrition – Undernutrition . . . . . . . . . 18 1.3.1.2. Interaction between undernutrition and inflammation . . . . . . . . . . . . . . . . . . 18 1.3.1.3. Malnutrition – Overnutrition . . . . . . . . 19 1.3.2. Screening for malnutrition . . . . . . . . . . . 20 1.3.3. Nutritional Assessment . . . . . . . . . . . . . 20 1.3.4. Techniques used in nutritional assessment . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.3.4.1. Anthropometry . . . . . . . . . . . . . . . . . . . . 23 1.3.4.2. Advanced measures of function . . . . . . 24 1.3.4.3. Laboratory Tests . . . . . . . . . . . . . . . . . . . . 24 1.4. The influence of malnutrition on function . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.4.1. Cognitive function . . . . . . . . . . . . . . . . . . 28 1.4.2. Muscle function . . . . . . . . . . . . . . . . . . . . 28 1.4.3. Cardiovascular function . . . . . . . . . . . . . 28 Basics in Clinical Nutrition 5.indd 17 1.4.4. 1.4.5. 1.4.6. 1.4.7. 1.4.8. 1.4.9. 1.4.10. 1.5. Renal function . . . . . . . . . . . . . . . . . . . . . 28 Respiratory function . . . . . . . . . . . . . . . . 29 Gastrointestinal tract . . . . . . . . . . . . . . . 29 Thermoregulation . . . . . . . . . . . . . . . . . . 29 Immune system . . . . . . . . . . . . . . . . . . . . 29 Wound healing . . . . . . . . . . . . . . . . . . . . . 30 Quality of life . . . . . . . . . . . . . . . . . . . . . . 30 Overnutrition – functional and clinical consequences . . . . . . . . . . . . . . . 31 1.5.1. Physiology of adipose tissue . . . . . . . . . . 31 1.5.2. Acute overfeeding . . . . . . . . . . . . . . . . . . 33 1.5.3. Chronic overfeeding – Obesity . . . . . . . 33 1.5.3.1. Aetiology of obesity . . . . . . . . . . . . . . . . . 33 1.5.3.2. Classification of obesity . . . . . . . . . . . . . 35 1.5.3.3. Obesity and metabolic complications . . . . . . . . . . . . . . . . . . . . . . 35 1.5.3.4. Metabolic syndrome . . . . . . . . . . . . . . . . 36 1.5.4. Treatment of obesity . . . . . . . . . . . . . . . . 36 1.6. Prevalence of malnutrition . . . . . . . . . 39 1.6.1. Malnutrition . . . . . . . . . . . . . . . . . . . . . . . 39 1.6.2. Identifying malnutrition . . . . . . . . . . . . . 40 1.6.3. Prevalence of malnutrition . . . . . . . . . . . 41 1.6.3.1. Underweight and BMI in different countries and world regions . . . . . . . . . 41 1.6.3.2. Prevalence of Malnutrition in a European Country (United Kingdom (UK)) . . . . . . . . . . . . . . . . . . . . 43 1.6.3.3. Geographic location (geographic inequalities) . . . . . . . . . . . . . . . . . . . . . . . 45 1.6.3.4. Distribution of malnutrition according to individual characteristics . . . . . . . . . . 46 1.6.4. Causes of malnutrition (undernutrition) and evidence for treatment . . . . . . . . . . . 46 1.7. Nutritional requirements for health at rest and upon exercise . . . . . . . . . . . . 48 1.7.1. Adult subjects . . . . . . . . . . . . . . . . . . . . . . 48 1.7.1.1. Macronutrients . . . . . . . . . . . . . . . . . . . . . 48 1.7.1.2. Micronutrients . . . . . . . . . . . . . . . . . . . . . 53 5.8.2019 11:45:01 XVIII Basics in Clinical Nutrition 1.7.2. Nutritional needs of infants, children and adolescents . . . . . . . . . . . . . . . . . . . . 55 1.7.2.1. Nutrient requirements for growth and development . . . . . . . . . . . . . . . . . . . 55 1.7.2.2. Nutrient requirements . . . . . . . . . . . . . . 57 2. Nutritional Physiology and Biochemistry . . . . . . . . . . . . . 69 2.1. 2.1.1. 2.1.2. 2.1.3. 2.1.4. 2.1.5. 2.2. Appetite and its control . . . . . . . . . . . . . Peripheral signals . . . . . . . . . . . . . . . . . . . Homeostatic control of feeding . . . . . . . Hedonic control of feeding . . . . . . . . . . . Loss of appetite during disease . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . Digestion and absorption of nutrients . . . . . . . . . . . . . . . . . . . . . . . 2.2.1. Principal sites of digestion and absorption . . . . . . . . . . . . . . . . . . . . . 2.2.2. The small intestine . . . . . . . . . . . . . . . . . . 2.2.2.1. Carbohydrates . . . . . . . . . . . . . . . . . . . . . 2.2.2.2. Lipids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.2.3. Proteins . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.2.4. Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.2.5. Water, electrolytes, and trace elements . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.3. The absorptive functions of the colon . . . . . . . . . . . . . . . . . . . . . . . 2.2.3.1. Water and electrolytes . . . . . . . . . . . . . . . 2.2.3.2. Metabolic and digestive functions . . . . 2.3. Energy metabolism . . . . . . . . . . . . . . . . 2.3.1. Calorimetry for the measurement of energy expenditure . . . . . . . . . . . . . . . . . 2.3.2. Components of energy expenditure, measurement, and determinants . . . . . . 2.3.3. Disease-related alterations in energy expenditure . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Carbohydrate metabolism . . . . . . . . . . 2.4.1. Carbohydrates in normal metabolism . . . . . . . . . . . . . . . . . . . . . . . . 2.4.2. Regulation of glucose metabolism . . . . 2.4.3. Effects of stress on glucose metabolism . . . . . . . . . . . . . . . . . . . . . . . . 2.4.4. Metabolic responses to critical illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5. Lipid metabolism . . . . . . . . . . . . . . . . . . 2.5.1. Basic pathways in lipid metabolism . . . 2.5.2. Lipid metabolism in fasting conditions . . . . . . . . . . . . . . . . . . . . . . . . . Basics in Clinical Nutrition 5.indd 18 69 70 71 73 73 73 74 75 76 76 78 80 82 82 83 83 83 85 85 87 88 90 90 91 92 94 95 95 98 2.5.3. Influence of surgical stress, sepsis, and organ failure . . . . . . . . . . . . . . . . . . . 99 2.6. Protein and amino acid metabolism . . . . . . . . . . . . . . . . . . . . . . 101 2.6.1. Physiology . . . . . . . . . . . . . . . . . . . . . . . . 101 2.6.2. Protein turnover . . . . . . . . . . . . . . . . . . . 102 2.6.3. Metabolism of amino acids . . . . . . . . . 104 2.6.4. Whole body protein synthesis and/or breakdown . . . . . . . . . . . . . . . . . . . . . . . 104 2.6.5. Methods for measuring protein metabolism . . . . . . . . . . . . . . . . . . . . . . . 108 2.7. Water and electrolytes in health and disease . . . . . . . . . . . . . . . . . . . . . . . 112 2.7.1. Water and fluid compartments . . . . . . 112 2.7.2. Flux of fluid through the gastrointestinal tract . . . . . . . . . . . . . . . 114 2.7.3. Role of the kidney . . . . . . . . . . . . . . . . . 114 2.7.4. External fluid balance . . . . . . . . . . . . . . 116 2.7.5. Effects of starvation and injury . . . . . . 116 2.7.6. Electrolytes . . . . . . . . . . . . . . . . . . . . . . . 117 2.8. Physiological functions and deficiency states of trace elements and vitamins . . . . . . . . . . . . . . . . . . . . . 123 2.8.1. Trace elements . . . . . . . . . . . . . . . . . . . . 123 2.8.1.1. Zinc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 2.8.1.2. Copper . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 2.8.1.3. Iron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 2.8.1.4. Selenium . . . . . . . . . . . . . . . . . . . . . . . . . 124 2.8.1.5. Chromium . . . . . . . . . . . . . . . . . . . . . . . 125 2.8.1.6. Molybdenum . . . . . . . . . . . . . . . . . . . . . 125 2.8.1.7. Manganese . . . . . . . . . . . . . . . . . . . . . . . 125 2.8.2. Vitamins . . . . . . . . . . . . . . . . . . . . . . . . . 127 2.8.2.1. Thiamine (vitamin B1) . . . . . . . . . . . . . . 127 2.8.2.2. Riboflavin (vitamin B2) . . . . . . . . . . . . 127 2.8.2.3. Niacin (vitamin B3 or PP) . . . . . . . . . . . 127 2.8.2.4. Vitamin B6 . . . . . . . . . . . . . . . . . . . . . . . . 128 2.8.2.5. Folate . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 2.8.2.6. Vitamin B12 . . . . . . . . . . . . . . . . . . . . . . . 128 2.8.2.7. Biotin . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 2.8.2.8. Vitamin C . . . . . . . . . . . . . . . . . . . . . . . . 129 2.8.2.9. Vitamin A . . . . . . . . . . . . . . . . . . . . . . . . 129 2.8.2.10. Vitamin D . . . . . . . . . . . . . . . . . . . . . . . . 130 2.8.2.11. Vitamin E . . . . . . . . . . . . . . . . . . . . . . . . 130 2.8.2.12. Vitamin K . . . . . . . . . . . . . . . . . . . . . . . . 131 2.8.2.13. Vitamins – Summary of influence of metabolic stress . . . . . . . . . . . . . . . . . 131 2.8.2.14. Assessment of vitamin status in clinical practice . . . . . . . . . . . . . . . . . 131 2.9. Antioxidants in health and disease . . 133 5.8.2019 11:45:01 XIX Contents 2.9.1. Oxidative stress . . . . . . . . . . . . . . . . . . . 134 2.9.2. Oxidation in vivo and neutralisation of RNOS . . . . . . . . . . . . . . . . . . . . . . . . . 135 2.9.3. Dietary recommendations for antioxidants . . . . . . . . . . . . . . . . . . . . . . 136 2.10. Dietary fibre: metabolism and physiological effects . . . . . . . . . . . . . . . 137 2.10.1. Physicochemical properties and metabolism of fibre . . . . . . . . . . . . . . . . 137 2.10.2. Physiological effects and clinical implications of fibre in the gut . . . . . . 140 2.11. The role of gut bacteria in nutrition and metabolism . . . . . . . . . . . . . . . . . . 146 2.11.1. Recent innovations in gut microbiome research . . . . . . . . . . . . . . . . . . . . . . . . . . 146 2.11.2. Characteristics and regulation of the intestinal microbiome . . . . . . . . . . . . . . 147 2.11.3. Physiological functions of the intestinal microbiome . . . . . . . . . . . . . . . . . . . . . . 149 2.11.4. The role of the intestinal microbiome in obesity and the metabolic syndrome . . . . . . . . . . . . . . . . . . . . . . . . 151 2.11.5. The role of the intestinal microbiome in malnutrition/undernutrition . . . . . . 152 2.12. Simple and stress starvation . . . . . . . . 155 2.12.1. Energy stores . . . . . . . . . . . . . . . . . . . . . 155 2.12.2. Simple starvation . . . . . . . . . . . . . . . . . . 156 2.12.3. Stress starvation . . . . . . . . . . . . . . . . . . . 157 2.12.4. Malnutrition and the response to injury . . . . . . . . . . . . . . . . . . . . . . . . . . 158 2.13. Injury and sepsis . . . . . . . . . . . . . . . . . . 161 2.13.1. The effects of cytokines during injury and sepsis . . . . . . . . . . . . . . . . . . . . . . . . 161 2.13.1.1. Reaction of the immune system . . . . . 162 2.13.1.2. Endocrine changes during the inflammatory response . . . . . . . . . . . . . 163 2.13.1.3. The immune response exerts a high metabolic and nutritional cost upon the body . . . . . . . . . . . . . . . . . . . . . . . . . 163 2.13.1.4. Adverse effects of cytokines . . . . . . . . . 165 2.13.1.5. Antioxidant defenses are depleted by infection and trauma . . . . . . . . . . . . . . . 165 2.13.1.6. Influence of phenotype on the cytokine response. . . . . . . . . . . . . . . . . . 166 2.13.2. The neuroendocrine response . . . . . . . 167 2.13.2.1. Neural stimuli and the sympathetic nervous system . . . . . . . . . . . . . . . . . . . . 168 2.13.2.2. Endocrine effects on metabolism . . . . 169 2.13.2.3. Therapeutic implications . . . . . . . . . . . 170 Basics in Clinical Nutrition 5.indd 19 2.13.3. Metabolic response to injury, stress, and inflammation . . . . . . . . . . . . . . . . . 2.13.3.1. Stress response: . . . . . . . . . . . . . . . . . . . 2.13.3.2. Metabolic and biochemical response during the flow phase . . . . . . . . . . . . . . 2.13.3.3. Convalescent or anabolic phase . . . . . . 2.13.3.4. Treatment . . . . . . . . . . . . . . . . . . . . . . . . 2.14. Metabolic response to hypoxia . . . . . 2.14.1. Transient response to anoxia or acute hypoxia . . . . . . . . . . . . . . . . . . . . . . . . . . 2.14.2. Functional adaptation to hypoxia . . . . 2.14.3. Molecular adaptation to hypoxia . . . . . 2.14.4. Nutritional consequences of chronic hypoxia . . . . . . . . . . . . . . . . . . . . . . . . . . 2.15. Nutritional aspects of chronic inflammatory disease . . . . . . . . . . . . . 2.15.1. Chronic inflammation . . . . . . . . . . . . . 2.15.2. Characteristic disease processes or conditions . . . . . . . . . . . . . . . . . . . . . 2.15.3. Interventions . . . . . . . . . . . . . . . . . . . . . 2.16. Pathophysiological consequences of intestinal failure . . . . . . . . . . . . . . . . 2.16.1. Definition and classification of intestinal failure . . . . . . . . . . . . . . . . . 2.16.2. The process of digestion and absorption of food . . . . . . . . . . . . . . . . . 2.16.3. Mechanisms of intestinal failure in pathophysiological conditions . . . . . 2.17. Metabolic aspects of neurological disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.17.1. Denervation atrophy . . . . . . . . . . . . . . . 2.17.2. Metabolic consequences of muscle denervation . . . . . . . . . . . . . . . . . . . . . . . 2.17.3. Hormonal and systemic consequences . . . . . . . . . . . . . . . . . . . . . 2.17.4. Amyotrophic lateral sclerosis (ALS) . . 172 173 173 176 176 179 180 181 182 183 185 186 187 188 191 191 192 194 198 198 199 200 201 3. Indications for nutritional support . . . . . . . 205 3.1. Background . . . . . . . . . . . . . . . . . . . . . . 205 3.2. A clinical framework for considering the indications for nutritional support . . . . . . . . . . . . . . . . . . . . . . . . . . 205 3.3. A practical framework for considering the indications for nutritional support . . . . . . . . . . . . 207 3.3.1. Identify malnutrition or those at risk of malnutrition . . . . . . . . . . . . . . . . . . . . 207 5.8.2019 11:45:01 XX Basics in Clinical Nutrition 3.3.2. Treat malnutrition or those at risk of malnutrition with the appropriate type of nutritional support . . . . . . . . . . 209 3.4. Common indications for nutritional support according to healthcare setting and disease . . . . . . . . . . . . . . . . 209 4. Organization and legal aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 4.1. Organization of nutritional care . . . . 4.1.1. Policy, standards, protocols, and Nutrition Steering Groups (NSGs) . . . 4.1.2. Hospital food and catering . . . . . . . . . . 4.1.3. Education and training . . . . . . . . . . . . . 4.1.4. Dieticians . . . . . . . . . . . . . . . . . . . . . . . . 4.1.5. Nutritional Support Teams (NSTs) . . . 4.1.6. Purchasing and equipment . . . . . . . . . . 4.2. Ethical and legal aspects . . . . . . . . . . . 4.2.1. Beneficence and Non-maleficence . . . 4.2.2. Autonomy . . . . . . . . . . . . . . . . . . . . . . . . 4.2.3. Special situations . . . . . . . . . . . . . . . . . . 4.2.4. Justice . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 214 215 216 216 216 218 219 219 221 222 224 5. Substrates used in parenteral and enteral nutrition . . . . . . . . . . . . . . . . . . . . . . . 229 5.1. Energy . . . . . . . . . . . . . . . . . . . . . . . . . . . 229 5.1.1. Goals of nutritional support . . . . . . . . . 229 5.1.2. Energy intake during nutritional support . . . . . . . . . . . . . . . . . . . . . . . . . . 230 5.1.3. Energy intake and acute disease stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232 5.2. Carbohydrates . . . . . . . . . . . . . . . . . . . . 234 5.2.1. Carbohydrate metabolism and nutritional support . . . . . . . . . . . . . . . . 234 5.2.2. Carbohydrates used in nutrition support . . . . . . . . . . . . . . . . . . . . . . . . . . 237 5.2.3. Dosages of carbohydrates in parenteral and enteral nutrition . . . . . 239 5.3. Lipids . . . . . . . . . . . . . . . . . . . . . . . . . . . 244 5.3.1. Enteral nutrition . . . . . . . . . . . . . . . . . . 244 5.3.2. Parenteral nutrition . . . . . . . . . . . . . . . . 245 5.3.2.1. Different intravenous lipid emulsions for parenteral nutrition . . . . . . . . . . . . 245 5.3.2.2. Reduction of lipid peroxidation . . . . . 247 5.3.2.3. Lipid clearance . . . . . . . . . . . . . . . . . . . 247 Basics in Clinical Nutrition 5.indd 20 5.3.2.4. Dosage for intravenous lipid emulsions . . . . . . . . . . . . . . . . . . . . . . . . 5.3.2.5. Monitoring intravenous lipid emulsions . . . . . . . . . . . . . . . . . . . . . . . . 5.4. Proteins and amino acids . . . . . . . . . . 5.4.1. Requirements of proteins and amino acids in humans . . . . . . . . . . . . . 5.4.2. Requirements of protein and essential amino acids in disease . . . . . . 5.4.3. Sources and chemical nature . . . . . . . . 5.4.4. Assessment of the biological quality of proteins . . . . . . . . . . . . . . . . . . . . . . . . 5.4.5. Amino acids: the building blocks of protein . . . . . . . . . . . . . . . . . . . . . . . . . 5.5. Water and electrolytes during nutritional support . . . . . . . . . . . . . . . 5.5.1. Monitoring . . . . . . . . . . . . . . . . . . . . . . . 5.5.2. Normal requirements . . . . . . . . . . . . . . 5.5.3. Abnormal requirements . . . . . . . . . . . . 5.5.4. Oral rehydration solutions . . . . . . . . . . 5.5.5. Enteral nutrition . . . . . . . . . . . . . . . . . . 5.5.6. Subcutaneous fluids . . . . . . . . . . . . . . . . 5.5.7. Parenteral fluids . . . . . . . . . . . . . . . . . . . 5.6. Trace elements and vitamins in parenteral and enteral nutrition . . . . 5.6.1. Micronutrients and trace elements . . . 5.6.1.1. Individuals at risk of deficiency . . . . . . 5.6.1.2. Clinical deficiency syndromes and subclinical deficiency states . . . . . 5.6.1.3. Optimisation of provision of micronutrients . . . . . . . . . . . . . . . . . . 5.6.1.4. Legislation from the European Union and enteral nutrition (EN) . . . . 5.6.2. Trace elements in PN and EN . . . . . . . 5.6.3. Vitamins in EN and PN . . . . . . . . . . . . 5.7. Dietary fibre: definition and classification . . . . . . . . . . . . . . . . . . . . . 5.7.1. Definition . . . . . . . . . . . . . . . . . . . . . . . . 5.7.2. Classifications . . . . . . . . . . . . . . . . . . . . . 5.7.3. Fibre and GUT microbiota . . . . . . . . . . 5.8. Special substrates . . . . . . . . . . . . . . . . . 5.8.1. Antioxidants and phytochemicals in nutrition . . . . . . . . . . . . . . . . . . . . . . . 5.8.1.1. What is an antioxidant? . . . . . . . . . . . . 5.8.1.2. Damage associated with depletion of antioxidants . . . . . . . . . . . . . . . . . . . . 5.8.1.3. Who might benefit from antioxidant supplements: biomarkers of oxidative stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 247 249 249 250 250 251 251 254 255 255 255 256 256 256 257 258 258 258 259 259 260 261 263 265 265 266 269 271 271 271 271 272 5.8.2019 11:45:01 XXI Contents 5.8.1.4. Overview of antioxidant strategies . . . 272 5.8.1.5. Dietary antioxidants . . . . . . . . . . . . . . . 273 5.8.1.6. Some remaining questions related to antioxidant therapy: . . . . . . . . . . . . . 273 5.8.2. Nutrients that influence inflammation and immunity: omega-3 fatty acids . . . 274 5.8.2.1. Omega-3 (ω-3) fatty acids . . . . . . . . . . 274 5.8.2.2. Dietary sources and typical intakes of ω-3 fatty acids . . . . . . . . . . . . . . . . . . 275 5.8.2.3. Supplementation with long-chain ω-3 fatty acids alters the fatty-acid composition of plasma, cells, and tissues in humans . . . . . . . . . . . . . . . . . . . . . . . . 275 5.8.2.4. Mechanisms of action of long-chain ω-3 fatty acids, with a focus on inflammation and immunity . . . . . . . . 276 5.8.2.5. Experimental studies with long-chain ω-3 fatty acids . . . . . . . . . . . . . . . . . . . . 277 5.8.2.6. Fish oil in artificial nutrition support . . . . . . . . . . . . . . . . . . . . . . . . . . 277 5.8.3. Nutrients that influence immunity: experimental and clinical data . . . . . . . 280 5.8.3.1. Glutamine . . . . . . . . . . . . . . . . . . . . . . . . 280 5.8.3.2. Arginine . . . . . . . . . . . . . . . . . . . . . . . . . 282 5.8.3.3. Nucleotides . . . . . . . . . . . . . . . . . . . . . . . 283 5.8.3.4. Polyunsaturated fatty acids (PUFAs) . 284 5.8.3.5. Micronutrients . . . . . . . . . . . . . . . . . . . . 284 6. Techniques of nutritional support . . . . . . . 287 6.1. Enteral nutrition . . . . . . . . . . . . . . . . . . 6.1.1. Indications and administration of nutrition . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.1.1. Indications for enteral nutrition . . . . . 6.1.1.2. Contraindications to enteral nutrition . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.1.3. Routes for enteral tube feeding . . . . . . 6.1.1.4. Choice of feeding solution . . . . . . . . . . 6.1.2. Methods of delivering enteral nutrition . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.2.1. Oral nutritional supplements . . . . . . . . 6.1.2.2. Transnasal access . . . . . . . . . . . . . . . . . . 6.1.2.3. Endoscopic access: PEG, PEG-J, and D-PEJ . . . . . . . . . . . . . . . . . . . . . . . . 6.1.2.4. Surgical access: gastrostomy, needle catheter jejunostomy . . . . . . . . . . . . . . . 6.1.2.5. Administration of enteral tube feeds . Basics in Clinical Nutrition 5.indd 21 287 287 287 287 287 287 289 289 291 292 298 300 6.1.2.6. Equipment for delivering enteral nutrition . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.3. Diets for enteral nutrition . . . . . . . . . . . 6.1.3.1. Homemade enteral (tube) nutrition – blenderised tube feeding . . . . . . . . . . . . 6.1.3.2. Commercially prepared diets for enteral nutrition . . . . . . . . . . . . . . . . . . . 6.1.4. Pharmaceutical aspects in enteral feeding and drugs . . . . . . . . . . . . . . . . . 6.1.4.1. Basic principles and requirements . . . 6.1.4.2. General approach to evaluate a drug-nutrient regimen in enteral tube feeding . . . . . . . . . . . . . . . . . . . . . . 6.1.4.3. Feeding tube . . . . . . . . . . . . . . . . . . . . . . 6.1.4.4. Nutrients . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.4.5. Best practices for co-administration of drugs and enteral tube feeding . . . . 6.1.5. Complications of Enteral Nutrition . . 6.1.5.1. Gastrointestinal complications . . . . . . 6.1.5.2. Mechanical complications . . . . . . . . . . 6.1.5.3. Metabolic complications . . . . . . . . . . . 6.2. Parenteral nutrition . . . . . . . . . . . . . . . 6.2.1. Methods of delivering parenteral nutrition . . . . . . . . . . . . . . . . . . . . . . . . . 6.2.1.1. Peripheral parenteral nutrition (PPN) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2.1.2. Central parenteral nutrition . . . . . . . . . 6.2.1.3. Complications associated with central venous catheter insertion and care . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2.2. Different systems for parenteral nutrition (AIO vs. MB) . . . . . . . . . . . . . 6.2.2.1. Multiple bottle system . . . . . . . . . . . . . . 6.2.2.2. All-in-One (AIO) system . . . . . . . . . . . 6.2.3. Pharmaceutical aspects of parenteral nutrition support . . . . . . . . . . . . . . . . . . 6.2.3.1. How to prepare parenteral nutrition (PN) admixtures, and the role and function of the pharmacist . . . . . . . . . . 6.2.3.2. Stability and compatibility of parenteral nutrition (PN) admixtures . . . . . . . . . . . . . . . . . . . . . . . 6.2.3.3. Drugs and nutritional admixtures . . . . 6.2.4. Metabolic complications of parenteral nutrition . . . . . . . . . . . . . . . . 6.2.4.1. Clinically relevant acute metabolic complications . . . . . . . . . . . . . . . . . . . . . 6.2.4.2. Long-term metabolic complications . . . . . . . . . . . . . . . . . . . . . 301 303 303 307 314 315 315 317 318 318 319 320 321 322 324 324 324 328 336 342 342 342 345 345 354 362 371 371 374 5.8.2019 11:45:01 XXII Basics in Clinical Nutrition 7. Monitoring of nutritional support . . . . . . . 377 7.1. 7.1.1. 7.1.2. 7.1.3. 7.2. 7.2.1. 7.2.2. 7.3. 7.3.1. 7.3.2. 7.3.3. Clinical monitoring . . . . . . . . . . . . . . . Aims and objectives . . . . . . . . . . . . . . . . Integrated nutrition . . . . . . . . . . . . . . . . Parameters . . . . . . . . . . . . . . . . . . . . . . . Laboratory measures of response to nutrition . . . . . . . . . . . . . . . . . . . . . . Nitrogen balance . . . . . . . . . . . . . . . . . . Proteins as markers of nutritional status . . . . . . . . . . . . . . . . . . . . . . . . . . . . Refeeding syndrome . . . . . . . . . . . . . . Pathophysiological factors . . . . . . . . . . Clinical manifestations . . . . . . . . . . . . . Recommendations for prevention and treatment of RFS in adult patients at risk . . . . . . . . . . . . . . . . . . . . 377 377 378 378 379 379 380 383 384 385 387 8. Nutritional support in different clinical situations . . . . . . . . . . . . . . . . . . . . . . . 391 8.1. Nutritional support in severe malnutrition . . . . . . . . . . . . . . . . . . . . . 8.1.1. Nutritional support . . . . . . . . . . . . . . . . 8.1.2. Oral nutritional support . . . . . . . . . . . 8.1.3. Enteral nutrition . . . . . . . . . . . . . . . . . . 8.1.4. Parenteral nutrition . . . . . . . . . . . . . . . . 8.1.5. Monitoring . . . . . . . . . . . . . . . . . . . . . . . 8.1.6. Rehabilitation . . . . . . . . . . . . . . . . . . . . . 8.2. Perioperative nutrition . . . . . . . . . . . . 8.2.1. Preliminary remarks . . . . . . . . . . . . . . . 8.2.2. Patients at low risk from nutrition-related complications . . . . . 8.2.3. Malnourished patients . . . . . . . . . . . . . 8.2.4. Complicated surgical patients . . . . . . . 8.2.5. Prescription of feed . . . . . . . . . . . . . . . 8.2.6. Integration . . . . . . . . . . . . . . . . . . . . . . . 8.2.7. Implementation of evidence and adherence to guidelines . . . . . . . . . . . . 8.3. Nutritional support in critically ill and septic patients . . . . . . . . . . . . . . . . 8.3.1. Enteral versus parenteral nutrition . . . . 8.3.2. Energy supply . . . . . . . . . . . . . . . . . . . . . 8.3.3. Glucose and carbohydrates . . . . . . . . . 8.3.4. Lipids . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3.5. Proteins and amino acids . . . . . . . . . . . 8.3.6. Vitamins and trace elements . . . . . . . . Basics in Clinical Nutrition 5.indd 22 391 392 392 393 393 393 393 395 395 396 398 399 399 400 400 402 403 404 404 406 406 407 8.4. Nutritional support in inflammatory bowel disease . . . . . . . . 8.4.1. Effect of inflammatory bowel disease on nutritional status and metabolism . . . . . . . . . . . . . . . . . . . . . . . 8.4.2. Indications for nutritional support . . . 8.4.2.1. Treatment and prevention of malnutrition . . . . . . . . . . . . . . . . . . . . . . 8.4.2.2. Treatment of active phase . . . . . . . . . . . 8.4.3. Preoperative nutrition . . . . . . . . . . . . . . 8.4.4. Relapse prevention . . . . . . . . . . . . . . . . 8.4.5. Pharmaconutrition in IBD . . . . . . . . . . 8.4.6. Symptomatic therapy . . . . . . . . . . . . . . 8.5. Nutrition support in liver disease . . . 8.5.1. Oral diet . . . . . . . . . . . . . . . . . . . . . . . . . 8.5.2. Dietary supplements . . . . . . . . . . . . . . . 8.5.3. Enteral feeding . . . . . . . . . . . . . . . . . . . . 8.5.4. Parenteral nutrition . . . . . . . . . . . . . . . . 8.5.5. Conclusions for diagnosis related nutritional therapy . . . . . . . . . . . . . . . . . 8.6. Nutritional support in renal disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6.1. Pathophysiology . . . . . . . . . . . . . . . . . . 8.6.2. Nutritional therapy for patients with renal disease . . . . . . . . . . . . . . . . . . . . . . 8.6.2.1. Non-catabolic patients with stable chronic kidney disease (CKD) . . . . . . . 8.6.2.2. Non-catabolic CKD patients on chronic RRT (with or without malnutrition) . . . . . . . . . . . . . . . . . . . . . 8.6.2.3. Patients with AKI and HD/CAPD patients with acute catabolic disease . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6.2.4. Solutions for nutritional support . . . . . 8.6.2.5. Complications and monitoring of nutritional support . . . . . . . . . . . . . . . . 8.6.3. Nutritional management of renal transplantation (RTX) . . . . . . . . . . . . . . 8.7. Nutrition in pulmonary and cardiac disease . . . . . . . . . . . . . . . . . . . . 8.7.1. Epidemiology . . . . . . . . . . . . . . . . . . . . . 8.7.2. Pathophysiology and consequences of malnutrition . . . . . . . . . . . . . . . . . . . 8.7.2.1. Pulmonary disease . . . . . . . . . . . . . . . . . 8.7.2.2. Cardiovascular disease . . . . . . . . . . . . . 8.7.3. Nutritional support and intervention . . . . . . . . . . . . . . . . . . . . . . 8.7.3.1. Pulmonary disease . . . . . . . . . . . . . . . . . 8.7.3.2. Cardiovascular disease . . . . . . . . . . . . . 410 410 411 411 413 414 415 415 415 417 417 418 418 419 420 422 422 423 423 424 426 429 430 430 433 433 434 434 436 437 437 438 5.8.2019 11:45:01 Contents 8.8. Nutritional support in acute and chronic pancreatitis . . . . . . . . . . . . . . . 441 8.8.1. Acute pancreatitis . . . . . . . . . . . . . . . . . 441 8.8.1.1. Outcome predictors . . . . . . . . . . . . . . . . 442 8.8.1.2. Physiology and pathophysiology with respect to nutrition and fluid resuscitation . . . . . . . . . . . . . . . . . . . . . . 442 8.8.1.3. Treatment of acute pancreatitis . . . . . . 444 8.8.1.4. Nutritional support . . . . . . . . . . . . . . . . 445 8.8.2. Chronic pancreatitis . . . . . . . . . . . . . . . 449 8.8.2.1. Nutritional treatment in chronic pancreatitis . . . . . . . . . . . . . . . . . . . . . . . 449 8.9. Nutritional support for GI fistulas . . 452 8.9.1. Definition and classifications . . . . . . . . 452 8.9.2. General principles of fistula treatment . . . . . . . . . . . . . . . . . . . . . . . . . 453 8.9.3. Metabolic care and nutrition . . . . . . . . 454 8.9.4. Nutritional preparation for elective surgery of the persistent fistula . . . . . . 457 8.10. Nutritional support in extensive gut resection (short bowel syndrome) . . 459 8.10.1. Aetiology of short bowel syndrome . . 460 8.10.2. Pathophysiology . . . . . . . . . . . . . . . . . . . 460 8.10.3. Complications of SBS . . . . . . . . . . . . . . 461 8.10.4. Small bowel adaptation . . . . . . . . . . . . . 463 8.10.5. Management of SBS . . . . . . . . . . . . . . . . 463 8.10.6. Dietary management of SBS . . . . . . . . . 464 8.10.7. The role of the dietician and specialist nurse in SBS treatment . . . . . . 468 8.11. Nutritional support in the diabetic patient . . . . . . . . . . . . . . . . . . . 470 8.11.1. Dietary management of diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . 471 8.11.2. Nutritional support of the diabetic . . . 471 8.11.3. Perioperative management . . . . . . . . . . 474 8.12. Nutritional support in burn patients . . . . . . . . . . . . . . . . . . . . . . . . . . 477 8.12.1. Pathophysiology . . . . . . . . . . . . . . . . . . . 477 8.12.1.1. Fluid loss . . . . . . . . . . . . . . . . . . . . . . . . . 477 8.12.1.2. Metabolic response . . . . . . . . . . . . . . . . 477 8.12.2. Treatment . . . . . . . . . . . . . . . . . . . . . . . . 478 8.12.2.1. Fluid resuscitation . . . . . . . . . . . . . . . . . 478 8.12.2.2. Energy and substrate requirements . . . 479 8.12.2.3. Nutriceuticals in burns . . . . . . . . . . . . . 481 8.12.2.4. Route of nutritional administration . . 482 8.12.2.5. Non-nutritional measures . . . . . . . . . . 483 8.12.2.6. Monitoring the response to nutritional therapy . . . . . . . . . . . . . . . . . 483 Basics in Clinical Nutrition 5.indd 23 XXIII 8.13. Nutritional support in cancer patients . . . . . . . . . . . . . . . . . . . . . . . . . . 8.13.1. General features of the nutritional support . . . . . . . . . . . . . . . . . . . . . . . . . . 8.13.2. Nutritional regimen . . . . . . . . . . . . . . . . 8.13.3. Indications . . . . . . . . . . . . . . . . . . . . . . . 8.13.4. Perioperative nutrition . . . . . . . . . . . . . 8.13.5. Non-surgical cancer patients . . . . . . . . 8.14. Cancer cachexia . . . . . . . . . . . . . . . . . . 8.14.1. Definition and classification . . . . . . . . . 8.14.2. Pathophysiology . . . . . . . . . . . . . . . . . . . 8.14.3. Clinical impact of cachexia . . . . . . . . . 8.15. Radiation enteropathy . . . . . . . . . . . . . 8.15.1. Risk factors for RE . . . . . . . . . . . . . . . . . 8.15.2. Clinical approach . . . . . . . . . . . . . . . . . . 8.15.3. Role of oral dietetic regimens and parenteral nutrition . . . . . . . . . . . . . . . . 8.15.4. Nutritional regimen . . . . . . . . . . . . . . . . 8.15.5. Outcome . . . . . . . . . . . . . . . . . . . . . . . . . 8.16. Nutritional support in AIDS . . . . . . . 8.16.1. History and pathophysiology . . . . . . . . 8.16.2. Metabolic and nutritional consequences of HIV infection . . . . . . 8.16.3. Side effects of the drugs . . . . . . . . . . . . 8.16.4. Indications for and aims of nutritional support . . . . . . . . . . . . . . . . 8.16.5. Dietary counselling . . . . . . . . . . . . . . . . 8.17. Effect of anticachectic agents in cancer . . . . . . . . . . . . . . . . . . . . . . . . . 8.17.1. Appetite-stimulating agents . . . . . . . . . 8.17.2. Anticatabolic agents . . . . . . . . . . . . . . . 8.17.3. Anabolic agents . . . . . . . . . . . . . . . . . . . 8.17.4. Other agents . . . . . . . . . . . . . . . . . . . . . . 8.18. Nutrition and wound healing . . . . . . 8.18.1. Phases of wound healing . . . . . . . . . . . 8.18.2. Non-healing chronic wounds . . . . . . . 8.18.3. Local wound management . . . . . . . . . 8.18.4. Nutrition and wound healing . . . . . . . . 8.18.5. Special substrates and wound healing . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.19. Nutrition and pressure ulcers . . . . . . 8.19.1. Classification and aetiology of pressure ulcers . . . . . . . . . . . . . . . . . . . . 8.19.2. Pathophysiology . . . . . . . . . . . . . . . . . . . 8.19.3. Nutritional status and pressure ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.19.4. Nutritional management is relevant to total PU care . . . . . . . . . . . . . . . . . . . 485 486 486 488 488 490 496 496 497 501 503 504 504 505 506 507 509 509 510 510 511 513 514 514 516 517 517 519 519 521 522 522 523 525 525 526 526 527 5.8.2019 11:45:02 XXIV 8.19.5. Nutritional intervention and pressure ulcers – what is currently known . . . . . 527 8.20. Nutritional therapy for neurological disorders . . . . . . . . . . . . . . . . . . . . . . . . . 531 8.20.1. Nutritional assessment . . . . . . . . . . . . . 531 8.20.2. Nutritional requirements . . . . . . . . . . . 532 8.20.3. Nutritional support . . . . . . . . . . . . . . . 533 8.21. Eating disorders – Anorexia nervosa . . . . . . . . . . . . . . . . . . . . . . . . . . 536 8.21.1. Pathogenesis . . . . . . . . . . . . . . . . . . . . . . 537 8.21.2. Physiological changes . . . . . . . . . . . . . . 537 8.21.3. Clinical manifestations and complications . . . . . . . . . . . . . . . . . . . . . 537 8.21.4. Complications . . . . . . . . . . . . . . . . . . . . 539 8.21.5. Nutritional assessment . . . . . . . . . . . . . 539 8.21.6. Nutritional treatment . . . . . . . . . . . . . . 539 8.21.7. Long-term effects . . . . . . . . . . . . . . . . . . 540 8.22. Nutrition support in obese patients . . . . . . . . . . . . . . . . . . . . . . . . . . 542 8.22.1. The obesity paradox . . . . . . . . . . . . . . . . 542 8.22.2. Sarcopenic obesity . . . . . . . . . . . . . . . . 543 8.22.3. Consequences of obesity in the hospital setting . . . . . . . . . . . . . . . . . . . . 543 8.22.4. Critical care obese patients . . . . . . . . . . 544 8.22.5. Surgical obese patients . . . . . . . . . . . . . 545 8.22.6. Non-surgical obese patients . . . . . . . . . 545 8.22.7. Calories and Protein: how much? . . . . . 546 8.22.8. Micronutrient deficiencies . . . . . . . . . . 546 8.22.9. Drug avoidance to prevent obesity . . . 547 8.23. Nutritional consequences of bariatric and metabolic surgery . . . . . . . . . . . . . . 551 8.23.1. Principal bariatric and metabolic modalities . . . . . . . . . . . . . . . . . . . . . . . . 551 8.23.2. Perioperative nutritional management . . . . . . . . . . . . . . . . . . . . . . 551 8.23.3. Expected weight loss . . . . . . . . . . . . . . . 553 8.23.4. Early nutritional complications . . . . . . 554 8.23.5. Long-term nutritional and metabolic complications . . . . . . . . . . . . . . . . . . . . 555 8.23.6. Priorities in nutritional supplementation . . . . . . . . . . . . . . . . . . 556 8.23.7. Recommendations for pregnancy . . . . 558 8.23.8. Attention to children and adolescents . . . . . . . . . . . . . . . . . . . . . . . 558 8.23.9. Refeeding the undernourished bariatric subject . . . . . . . . . . . . . . . . . . . 559 8.24. Nutritional care of the polymorbid patient in medical wards . . . . . . . . . . . 561 Basics in Clinical Nutrition 5.indd 24 Basics in Clinical Nutrition 8.24.1. Pathophysiological considerations . . . 561 8.24.2. Practical consequences . . . . . . . . . . . . . 562 8.25. Nutritional support during pregnancy and breastfeeding. . . . . . . 565 8.25.1. Pathophysiology . . . . . . . . . . . . . . . . . . . 565 8.25.2. Indications for and aims of nutritional support . . . . . . . . . . . . . . . . . . . . . . . . . . 566 8.25.3. Parenteral nutrition in pregnancy and lactation. . . . . . . . . . . . . . . . . . . . . . . . . . 567 8.26. Nutritional support in neonatology . . . . . . . . . . . . . . . . . . . . . . 569 8.26.1. Enteral or parenteral nutrition? . . . . . . 570 8.26.2. Goals of nutritional support . . . . . . . . . 571 8.26.3. Early nutritional management . . . . . . . 572 8.26.4. Parenteral nutrition . . . . . . . . . . . . . . . 573 8.26.5. Complications of parenteral nutrition . . . . . . . . . . . . . . . . . . . . . . . . . 581 8.26.6. Monitoring of Nutritional Status . . . . . 582 8.26.7. Enteral nutrition . . . . . . . . . . . . . . . . . . 583 8.27. Nutritional support in infants, children, and adolescents . . . . . . . . . . 587 8.27.1. Diagnostic approach . . . . . . . . . . . . . . . 587 8.27.2. Nutritional support . . . . . . . . . . . . . . . . 589 8.27.2.1. Enteral nutrition . . . . . . . . . . . . . . . . . . 590 8.27.2.2. Parenteral nutrition . . . . . . . . . . . . . . . . 601 8.28. Nutrition in very old patients . . . . . . 611 8.28.1. Determinants of undernutrition in the elderly . . . . . . . . . . . . . . . . . . . . . . 612 8.28.1.1. Changes in body composition and function . . . . . . . . . . . . . . . . . . . . . . 613 8.28.1.2. Appetite in the elderly . . . . . . . . . . . . . . 615 8.28.1.3 Small-bowel bacterial overgrowth . . . . 617 8.28.1.4. The ageing immune system . . . . . . . . . 617 8.28.2. Drug interactions in the elderly . . . . . . 618 8.28.3. Undernutrition in the elderly and outcomes . . . . . . . . . . . . . . . . . . . . . . . . . 618 8.28.4. Detection of undernutrition in the elderly . . . . . . . . . . . . . . . . . . . . . . 619 8.28.5. Changes in nutrient requirements . . . . . 621 8.28.6. Nutritional intervention . . . . . . . . . . . . 623 8.28.7. Ethical considerations . . . . . . . . . . . . . . 626 8.29. Home artificial nutrition . . . . . . . . . . 628 8.29.1. Home parenteral nutrition (HPN) . . . 628 8.29.1.1. Indications for HPN . . . . . . . . . . . . . . . 629 8.29.1.2. Methods for HPN application . . . . . . . 630 8.29.1.3. Complications of HPN . . . . . . . . . . . . . 631 8.29.2. Home enteral nutrition (HEN) . . . . . . 632 8.29.2.1. Techniques of HEN . . . . . . . . . . . . . . . . 632 5.8.2019 11:45:02 XXV Contents 8.29.2.2. Complications of HEN . . . . . . . . . . . . . 8.29.3. How to begin home artificial nutrition . . . . . . . . . . . . . . . . . . . . . . . . . 8.30. Nutrition in sports . . . . . . . . . . . . . . . . 8.30.1. Energy expenditure during physical activity . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.30.1.1. Aerobic and anaerobic energy metabolism . . . . . . . . . . . . . . . . . . . . . . . 8.30.2.2. Anaerobic and aerobic pathways for energy production . . . . . . . . . . . . . . . . . 8.30.1.3. Exercise intensity and substrate utilisation . . . . . . . . . . . . . . . . . . . . . . . . 8.30.1.4. Adaptations in metabolic and physiological systems depend on the type of exercise . . . . . . . . . . . . . . . . . . . 8.30.2. Relative energy deficiency syndrome . . . . . . . . . . . . . . . . . . . . . . . . 8.30.2.1. Pathogenesis . . . . . . . . . . . . . . . . . . . . . . 8.30.2.2. Clinical and performance relevance of relative energy deficiency in sports . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.30.2.3. Diagnosis of relative energy deficiency in sports . . . . . . . . . . . . . . . . Basics in Clinical Nutrition 5.indd 25 633 633 635 636 636 637 640 641 641 642 642 642 8.30.2.4. Treatment of relative energy deficiency in sports . . . . . . . . . . . . . . . . 8.30.3. Sport-specific nutrition: The endurance athlete . . . . . . . . . . . . . . 8.30.3.1. Recommendation for daily nutrient intake for endurance athletes . . . . . . . . 8.30.3.2. Nutritional preparation of an endurance athlete for competition . . . 8.30.3.3 Recommendations for food and fluid intake during endurance competitions . . . . . . . . . . . . . . . . . . . . . . 8.30.3.4. Nutrition for recovery from competition or exhausting training sessions . . . . . . . . . . . . . . . . . . . . . . . . . . 8.30.4. Sport-specific nutrition: Power and strength sports . . . . . . . . . . . . . . . . . . . . 8.30.4.1. Carbohydrate intake for power and strength sports . . . . . . . . . . . . . . . . . . . . 8.30.4.2. Protein intake for power and strength sports . . . . . . . . . . . . . . . . . . . . 8.30.4.3. Fat intake . . . . . . . . . . . . . . . . . . . . . . . . . 8.30.5. Nutritional supplements in sports . . . . . 643 645 645 647 647 648 648 649 649 651 651 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 655 5.8.2019 11:45:02
